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If the Supreme Court overturns Roe v. Wade, the change would pose a serious threat to maternal health in the United States, experts say.

A leaked draft opinion published Monday by Politico suggests that the court could overturn the seminal ruling that gave the Constitution the right to abortion nearly 50 years ago. The court confirmed the authenticity of the draft; a final decision is not expected until late June or early July.

If Roe is overturned, nearly two dozen states could ban abortion or severely restrict it. According to an NBC News analysis of data from the Center for Reproductive Rights, thirteen have “trigger laws” that would ban abortion almost immediately.

Studies show that bans and restrictions would have multiple effects on maternal health. On the one hand, if more pregnant people do not have access to the abortions they seek, they will bear the risk of relatively high and rising mortality from pregnancy-related causes in the United States, which is particularly high among people of color.

Dr. Amy Ardant, an obstetrician-gynecologist and reproductive health physician researcher in Illinois, said, “There will be women who will die from pregnancy as a result of this decision.”

In addition, in states where abortion is banned, pregnant women will be at risk of being prosecuted for seeking a termination, and studies have shown that unintended pregnancies can have many harmful long-term consequences for the mother, including higher financial hardship and severe effects on mental health.

Experts fear rise in maternal mortality
The United States has the highest maternal mortality rate of any developed country. According to the Centers for Disease Control and Prevention, a total of about 700 women die each year in the United States from pregnancy-related complications, and about three-fifths of those deaths are preventable.

“One of my biggest concerns is that if Roe is overturned, we will see an increase in maternal deaths in this country,” said Lauren Ralph, an epidemiologist at the University of California, San Francisco.

The maternal mortality rate in the United States in 2020 is 23.8 deaths per 100,000 live births, the highest level since before Roe was overturned, according to the Commonwealth Fund, which works to provide better health care to underserved communities. The death rate for blacks is much higher: 55.3 deaths, almost three times the rate for whites.

As a result, the rise in maternal mortality may be “concentrated among people of color who live below the federal poverty line,” Ralph said.

The maternal mortality rate in the United States more than doubled from 1987 to 2017, according to the CDC. In contrast, maternal mortality rates in high-income countries have declined slightly on average each year over roughly the same period, according to a 2016 study.

Some studies suggest that women who are denied abortions are at particularly high risk for pregnancy-related health problems, in part because of the increased likelihood of delayed prenatal care. A study published last year found that while most U.S. states had similar maternal mortality rates in 1995, by 2017, states that restricted abortion had significantly higher rates than those that adopted more protective policies.

“The risk of medical complications from unintended pregnancies is higher, and that risk may be exceeded once the baby is born,” Addante said.

That’s also the finding of a five-year research project by the Bixby Center for Global Reproductive Health at the University of California, San Francisco, called the Turnaway Study, which surveyed 1,000 women seeking abortions at 30 facilities in the United States. In the group, women who were denied abortions had more serious health problems, such as high blood pressure or seizures, than women who had abortions. Two women who were denied abortions died from pregnancy-related illnesses.

“We can say with certainty that those maternal deaths could have been avoided if these people had access to the care they wanted,” said Ralph, one of the study’s researchers.

Safe abortion options may be hard to come by
Experts say overturning Roe is unlikely to lead to more unsafe abortions in the U.S., despite the opportunity.

“In terms of unsafe abortions, ‘back roads’ or unskilled abortion providers and women who die from unsafe abortions, I really hope that’s not what we’re seeing. It’s a risk, but I hope it’s not,” said the director of the Jacobs Institute for Women’s Health at George Washington University.

A major difference for women seeking abortions now compared to the pre-Roe era is the abortion pill approved by the U.S. Food and Drug Administration in 2000. The regimen consists of mifepristone, which blocks progesterone, and misoprostol, which induces contractions. The combination can be taken for up to 10 weeks after a patient’s last menstrual period; FDA regulations require that the pills be dispensed only by registered providers.

By 2020, half of all abortions in the United States use this drug combination, according to the Guttmacher Institute, an abortion rights advocacy group. In December, the FDA decided to permanently allow patients to receive pills by mail after telemedicine appointments. But six states – Arizona, Indiana, Montana, Ohio, Oklahoma and Texas – have made it illegal.

Medication abortion is very safe: a 2018 report by the National Academy of Sciences in 2018 found that only a small percentage of patients experience complications. A recent study published in February found that about 1 percent of people who self-administered medication abortions experienced adverse reactions and no one died.

Still, it’s not the right choice for everyone seeking an abortion, Addante said.

“It doesn’t replace the need for procedural abortion because there will be people who think it’s just a safer option or that it’s more appropriate for personal reasons,” she said.

If Roe is overturned, some people who become pregnant will not have access to either option. Experts say they are concerned about the legal consequences.

“People are more likely to be convicted, jailed, prosecuted and imprisoned for managing their abortions than for experiencing any medical complications,” said Dr. Jamila Perritt, president and CEO of Reproductive Health Physicians.

She added that people of color, immigrants and the LGBTQ community are among the biggest targets for criminalization.

“My biggest concern right now is seeing an already very marginalized population pushed even further to the edge in terms of their ability to access reproductive health care,” Adante said.

Long-term consequences of unintended pregnancies
In a 2020 analysis of Turnaway Study data, researchers found that more than half of the participants reported that the decision to have an abortion was difficult. Soon after, these women were more likely to report feeling sad, guilty and angry. However, by five years later, 84 percent reported positive or neutral feelings.

Experts describe the negative effects of denying someone a desired abortion as long-term and intergenerational.

A 2017 British study specifically looked at the mental health effects of unplanned births on women with partners and found that nine months after birth, they were almost twice as likely to suffer psychological distress as women with planned pregnancies.

Addante said, “If people are forced to continue a pregnancy and they either don’t want to continue it or it’s not safe to do so, we’re going to see an increase in potentially adverse mental health outcomes.”

In the Turnaway study, women who were denied abortions were found to be more likely than women who had abortions to remain in contact with violent partners and to have difficulty affording basic living expenses. Their children were more likely to live below the federal poverty line than children born to women who had previously had abortions.

“Most people who seek abortions are already parents, so they know what it means to have a child,” said Perritt. “They are making decisions about access to abortion care in a way that allows them to continue to care for the children they already have.”


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